Provider Demographics
NPI:1770531311
Name:GHENA, DAVID RICHARD (DHSC PT SCS ATC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:GHENA
Suffix:
Gender:M
Credentials:DHSC PT SCS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5911 W BASELINE RD STE 102
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2811
Practice Address - Country:US
Practice Address - Phone:480-281-6103
Practice Address - Fax:623-267-2654
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007154225100000X
MI5501005458225100000X
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8342073Medicaid
S57495Medicare UPIN
WAAB13919Medicare ID - Type Unspecified
WAAB13920Medicare ID - Type Unspecified